If I Were Your Spine Surgeon…

As a spine surgeon, who has been practicing surgery for over 30 years, I have attacked top-level fellowship spine problems with a fury. Convinced that I could help almost anyone in pain with definitive intervention such as surgery, I began to notice an inconsistency between the success of my surgeries and its benefit to the patient. Why, I would ask myself, that even with the best performed surgery, did patients have complications? It took me eight years to understand that surgery was just one specific tool in treating a complex pain problem and it’s not for everyone.

Here are some of my insights:

You can only fix what you can see. Surgery should only be performed for an anatomic problem that is clearly seen on an advanced imaging study and the symptoms must match. Operating on pain rarely works and has been shown to induce or create more pain up to 40% of the time.

Even with a clear-cut (pun intended) surgical problem the research shows you must first address all other aspects of pain in order to optimize your chances of a good outcome. This includes:

Getting adequate sleep

Calming the nervous system by decreasing:

Depression

Anxiety

Fear-avoidance

Anger

Stabilizing mood-altering medications

Physical conditioning

Life outlook

If you are of the opinion that you simply want an operation and refuse to address these other issues, I will not be your surgeon. It would be completely irresponsible of me to allow you to decrease your chances of a successful outcome and expose you to the risk of increasing your pain, knowing that you have not addressed the core issues. It’s because of this that failures I had years ago are now a very rare occurrence.

You are the only one who is experiencing the pain. If your pain is mild and tolerable – I suggest that you do not undergo surgery.
Outside stresses affect the body’s chemistry and perception of pain. I have never made a decision to do surgery around the time of a major loss. Many situations are indescribably awful. You will not do well. I see you as a whole and complete person and do my best to discover what’s happening in all areas of your life.

Dr. David Hanscom

It’s been fascinating and unexpected that many of my patients with severe narrowing of the spinal canal, called spinal stenosis, have cancelled their surgeries as their pain decreased to the point where it was not worth the risk of performing surgery. In my first book, Back in Control: A Spine Surgeon’s Roadmap Out of Chronic Pain, I recommended surgery more aggressively if a patient was suffering from chronic pain. It seemed logical to me that he or she could not tolerate additional stress of a symptomatic bone spur. But since then, we now know that the chronic pain circuits are already fired up and that the additional stress of surgery frequently increases the pain. Enough patients have gone pain free without surgery that it is becoming somewhat challenging to sustain an elective surgical practice.

One of the most disheartening situations I see is when patients have damaged spines as a result of multiple failed surgeries. When I look at the original scans they frequently reveal a normal spine for his or her age. One woman spent over 20 years in a wheelchair from her spine breaking down over a low back fusion. Much of my practice is to salvage what I can. Rarely can I get them back to normal, however, without having prior surgery, I have seen many patients not only return to full function, but become more active than they ever have been.

Surgery is only one tool that can solve a specific structural problem. It is rarely “the definitive solution.” Don’t let anyone place a knife in your back until you understand chronic pain. And most important take back control of your own care.

Dr. David Hanscom is a leading orthopedic spine surgeon at the Swedish Neuroscience Institute in Seattle, WA. Though he believes that surgery and medication have a role, he knows that these standard courses of treatment aren’t what’s needed to treat chronic pain. Instead he provides the framework so the patient can find his or her solution allowing them to live free of pain, forever. His method, which transforms all kinds of pain, including back, neck, arthritis, fibromyalgia, and migraines, is explained in BACK IN CONTROL A Surgeon’s Roadmap Out of Chronic Pain. Website: www.backincontrol.com

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Kathy (and Danny),
I 100% agree with your fine explanation. We all have our stories.
I was Dx’d with PTSD while in on/off therapy after my auto accident and life changing happenings, becoming disabled etc etc.
I was tremendously hurt, confused and sad for a long time.
After awhile I couldn’t stand to go. I couldn’t stand sitting there having someone dig deeper and deeper into my life, childhood, whatever… to find a reason for my ongoing sadness. I couldn’t stand crying anymore!!!
Regardless of how my life has been..I truly am a ‘happy spirited’ person and greatly despised feeling lost and down and being mistreated by doctors and family.
Fast forward, I still have trouble accepting my life as it is, I still despise it all…I’m very aware of my existence as it is…
but I, and only I, totally understand why I have trouble accepting it!
I’ve become ‘used to it’ in a sense (I have no other choice) but…
I just don’t WANT to live this way! I want a real life! I want to be well taken care of and I’m not at all. I am alone in this.
I’m stuck in this painful body just trying to survive through each day.
It’s a huge struggle. And that is ‘traumatic’ for me most everyday.
But, I have God to lean on and that works for me. I don’t need to trudge deep into the past or relive my accident and the thereafter anymore. Its too painful.
It is what it is and I just need help surviving.
May God bless us all with reasons to smile today. Keep strong!

Danny “After stewing on this for several days now, I have to admit that I felt offended at hearing (or reading) “we all probably have PTSD…”. It has brought back all the ugly memories of the many times I’ve heard people say “I have headaches, too”

Like our pain is all different; PTSD is different for everyone too. Do you want the ugly details of my PTSD? You think none of us have suffered with those same “you just need to relax” or “If I can get over my surgery then you can get over your accident” responses? Of course we all heard these things too.

PTSD – Post Traumatic Stress Disorder is very common in pain patients because of the trauma caused by the accident/injury like a car accident [literally shaking typing this…] There’s a reason why so many of us ‘likely have PTSD’ and it’s not minimizing anyone else’s experience. But no one is an island unto himself suffering. We are unique with many of the same problems. No two of us experience pain the same, no two people will end up with PTSD the same either.

PTSD doesn’t need to happen in a combat situation. Though being beaten and raped is a form of combat all by its own self.

Most of the time pain is the end result of trauma. Regardless of how that trauma happened. I get that combat trauma-PTSD is very harsh to live with; some pain disorders are very hard to live with and no ‘traumatic’ injury needs to happen for them to be in such pain. The system can make the strongest of us nervous wrecks.

Generalized anxiety disorder is what most of us have no doubt.
Panic attacks that bring you to your knees isn’t something that everyone with general anxiety disorder have either. But if you add up traumatic events + traumatic injury resulting in disability + generalized anxiety disorder with panic attacks it is safe to say you have PTSD.
If your psychiatrist dx PTSD after hearing how you come to shake, struggle to sleep and/or haunted by nightmares [everyone has different experiences too] and your panic attacks are so severe your heart rate goes into heart attack zone [157/110 is highest I recall on the down side of a panic attack….the other side of the peak] then it is PTSD.

Am I offended that someone in *only* a car accident claims to have PTSD and chronic pain? NEVER. It’s not the same as being told your pain and panic/anxiety is all in your head by the clueless, non-suffering person.

Does someone have to go to war to end up with PTSD? Absolutely not but those that do suffer even harder IMHO with nightmares. Non-combat PTSD and combat PTSD is like saying the pain is the same for Fibromyalgia as it is for CRPS. Which as we all know it isn’t the same, either. It is chronic pain tho.

Sorry for you feeling diminished in your suffering because of how many in chronic pain also have either GAD/PTSD.

I am sorry, I meant people with Chronic Pain. Many of us have been through traumatic events, difficult and intrusive Surgeries. When we couple this with having to engage with the healthcare system, which in most cases does not recognize Chronic Pain, have their own misguided theories about it. Physicians are afraid to even discuss it, Some of us endure months or years of untreated pain, and when we finally see a Physician after numerous referrals and “Alternative Treatments’ we are not believed. This is itself can be traumatizing. In general many “Therapists” have magical beliefs about Pain, and in some cases this is so entrenched that they refute Physical Evidence of an underlying Physical Issue. Apparently they ‘Believe” that looking at an MRI Report or an X-Ray only encourages the Patients, pain.
What I was trying to say, is that seeing a “Therapist” can be Re-Traumatizing. It is almost as if they expect us to Prove something or deny we are in pain. Then they often go after painful Childhood experience to seek out a cause. When a person is in pain and asked to recall painful experiences it might trigger more pain, trauma and distress. There really are no “Studies” or Research on this topic. Once again “Treatment” is a catch as catch can grey area, where beliefs and pseudo Science are applied.
Since there is no Science or Research done on this topic, we have no idea if it works or not. We need to ask, compared to what. The way that the “Therapy Industry” treats people with Chronic Pain, has no Scientific Research to back it up. The only Studies we have are really Apples and Oranges. They did not follow any Cohort of People who did not seek treatment, and compare the to those that did. They also failed to remove or adjust Factors like “Positive Human Interaction” whether it was the Therapy or just interacting with another human being. Psychology Researchers do not make Distinctions like the duration, intensity or amount of Chronic Pain. If we look at the Research done there is no distinction between people with serious underlying Injuries, or a person who played too much golf. This makes most of their Research suspect. There is a reason they do not break these categories down. It is easier for the to make broad and misleading Conclusions, and even peddle some Pharma, while Marketing their Industry. Retraumatizing, is a Con Game, it keeps people coming back. They did not do any Research on this either, it was unprofitable for them.

FYI, my counselor didn’t shut me down from talking about my chronic pain when she diagnosed me with PTSD. In fact, it was the complete opposite. She didn’t attribute my pain to PTSD or any other psychological problems. She attributed my PTSD to being electrocuted for 12-15 minutes, being clinically dead before being resuscitated and having a 16 hour window of absolutely no memory whatsoever, even though I became conscious and interacted with the medical staff and my family for several hours.

The stresses of clinically diagnosed PTSD make life quite difficult. Adding that that to the severe, high-level pain I’m cursed with on a daily basis is even more difficult. At least with the PTSD, I can actually take actions that may help, as opposed to having a Traumatic Brain Injury that nobody can do anything about.

After stewing on this for several days now, I have to admit that I felt offended at hearing (or reading) “we all probably have PTSD…”. It has brought back all the ugly memories of the many times I’ve heard people say “I have headaches, too” or “my uncle’s an electrician and he’s been shocked a lot”, as if either is anywhere close to what I’ve been through. But I sure didn’t expect to experience it from a fellow pain sufferer

I know the isolation, depression and bleak outlook on life. But, please know you are not alone.
None of us are alone. We are together and one on this. I was feeling SO alone until I read your stories and I realized that I was not alone. I know, I hate that you have/had these issues, but you inspire me and I no longer feel so quite “all alone”.
Thank you
R B

Danny, thank you for your response to me and the others. I’m truly am so sorry for all that you also have been through. I cannot imagine being electrocuted and then losing all that you have. Keep strong, I enjoy reading your posts.
Sherry, my story is quite similar to yours. I too was a nurse (32 yrs) when my pain journey began from popping L4, then having an anterior/posterior fusion a year later. Ive been in pain everyday since that injury and the surgery left me with nerve pain, numbness in LLE etc etc. But I managed to continue to work for the next 13 yrs., although each day was very tough, until some woman speeding and on her cell phone slammed into my car while on my way to a patient’s home to do infected wound care.
That was the day my life changed (that ow,a had no idea what she did to me)
and I’ve been disabled since… Loss of career, 3 more lumbar spine surgeries, fusions, hardware, hardware removal!, C-spine dysfunction, BUE weakness/issues, occ. falls, have broken both shoulders in falls,
developed Fibromayalgia which is worsening with age, etc etc and have lived a very small and isolated life since.
All of our stories amazingly intertwine and we all understand each other so well.
God bless all Chronic Pain warriors and thank you for always reminding me that I am never alone.
It amazes ,

We probably all have some version of PTSD, from dealing with Pain, the System, and even fro repeating this in “Therapy.” One way they shut down the discussion of Pain, especially all of the people who thought that “Therapy” could not hurt. The fact that some of us went that route, made the situation even more difficult. Since people with pasin sought a Psychological Intervention, they were able to label us all as having a “Mental Health Issue.” This is a carefully crafted self repeating Strategy to shut us down.
If we follow the Media coverage of this issue, any reference to pain has been removed. The DSMV the Psychologists Bible was rewritten to avoid the Subject, and confuse it. Depending on the Patients Income and Social Status the Psychologists “Believe” that Pain is not the result of a Physical Problem, but some manifestation of inner deficiencies, or personality. This is no longer a fact or evidence3 based subject. It is about what is ore Profitable.
I suspect seeing a Psychotherapist can be counter productive. They are trained to create a dynamic where we are supposed to ignore pain. The way they expect to be convinced or have to have it explained repeatedly is further traumatizing, thus making us more insecure and dependent on them. A “Pain Journal” to a Psychologist would make it appear that we are focusing on our Pain, as they interpret it. There would of course be a negative Interpretation attributed to Journaling.
There are older and more experienced Psychologists or Psychiatrists who may still have an open mind, but they are leaving the Profession. They are being replaced by the one who “Believe.” This is no longer an Evidence Based Field, they are just as responsive to the current false narrative as anyone else. It is more profitable to believe that Depression causes Pain, rather than the reverse.

Justlike all chronic pain patients are different, all spine surgeons are different too.

Mine is not motivated by money (he makes a good living I am sure) but he works as head of the spinal department at a teaching/research hospital. He is researching chaining fluids/disc/stuff material to help paraplegics regain the ability to walk and I know this because he has asked permission to use some of mine.

He can read “the edges” of films and find fractures that not even being looked for. (just looking for what is causing this pain)He takes patients into the room and shows them the images and where the problem disc/etc. is. He is VERY GOOD at what he does and I travel a long way to go to him.

Please don’t throw out the baby with the bath water.

Some surgeries DO WORK and prevent damage from getting worse..possibly compromising your ability to walk.

SANDY AURIENE SULLIVAN – like you & R BELCHER, I suffer from serious PTSD (non-combat). 3/3/1991 is when my accident occurred, but it was 24 years later (2015), while seeing a psychologist/counselor for help with still dealing with the pain and other issues in my so-called “life”, when she said that I “clearly suffer from serious PTSD”. I was stunned! My surprise came from the fact that I do as much research on my health issues as possible, but I never even thought about PTSD. Knowing and accepting a condition is the first step towards dealing with it, and I am trying.

HJ – (just in case you haven’t put it together) SANDY & MAUREEN each explain how to create & maintain a pain journal. Our pain issues are usually very unique. And creating & keeping a pain journal can be unique, as well. I hope you have begun – starting one and updating it on a daily basis (at first) is the hardest part. Once you have created one that is best for you and updated it for the 1st few weeks, then it becomes second nature. Good luck, HJ!

MAUREEN – I know how blessed I am to have such an excellent Pain Management Specialist. The story about how I found him in a clear demonstration of how His will is done and how prayers ARE answered, but it’s too long for this place. (I’d love to share it with you some day!) But here’s an example of how He was involved in steering me to the right Dr for me: This Dr’s first college degree is in Electrical Engineering (EE). He then decided to pursue neurology and finally became a neuropsychiatrist and a certified Pain Management Specialist (and a practicing psychiatrist). His first degree is important because my chronic, high-level pain is due to being electrocuted in a flooded basement! It’s not that he knew everything simply because of his EE degree, but he was the first doctor I’d found who understood electricity and its potential effects on the human body. He immediately approached my treatment from a unique angle, different from every other doctor I’d seen in the previous 11-12 years. I am so blessed, and I am so grateful to Him who guided me!

Finally, I have to mention the post by SHERRY SHERMAN. First, I have to say that I am so sorry for what you’ve endured, Sherry. “Hell on Earth” doesn’t seem to do it justice. But, as an example of those who suffer with chronic, high-level pain, here is someone who is well-educated and experienced in health care. Someone who, as a RN, has seen a lot of health and injury issues. Unfortunately, she is now experiencing the horrible pain & suffering that comes from doctors who are arrogant and have a “know-it-all” syndrome, some who won’t admit errors and/or missed conditions. (I have a familiarity w/ that syndrome because, for several years, I was working as pharmaceutical sales representative for a division of Johnson & Johnson at the time of my accident.) Her surgeries have created a far worse condition that may possibly be helped with future procedures, but it can never be completely undone. And she has to suffer from severe pain because of the absurd CDC guidelines?!! The pain organizations should consider using Sherry’s condition as an example of the unintended, collateral damage of their “one-size-fits-all” approach to the treatment of pain. And what’s worse, I’m sure there are so many others out there who suffer just as much, if not more. And it doesn’t matter whether our conditions are the result of a doctor’s mistake, an inherited or contracted condition or an accident – CHRONIC, HIGH-LEVEL PAIN NEEDS TO BE TREATED! There are no appropriate “guidelines” for Sherry’s condition, or for most everyone who reads this.

I have had scoliosis for 27 Years. It started at 14 and at 17 the thoracic curve was measured at 54 degrees to the right. To compensate i had a lumbar curve to the left. The pain grew with age, and I tried many different therapies to help me. None of them did and I was forced to turn to the expertise of highly reputable surgeon in London at age 37. Thankfully, for me, he said it was not advisable to operate at my age and would cause greater distress and trauma to my body than I was already experiencing. I was told to learn to manage it more effectively. Mmmmm. I felt pretty hopeless.
I was then blessed to be gifted the expertise of http://www.BoneandBodyClinic.com.
After 7 months of committed treatment, free of any blade… my spine is slowly straightening and my pain is now minimal. This clinic treats many spinal and skeletal issues, it is their forte!
There are many options, please remember that and share!

Sandy, I’m so glad to hear that you do also…
I’ve kept a pain journal since 2004. Years ago a ‘new at that time’ pain management doc told me to stop journaling though since it keeps too much focus on my pain issues.
And so, I did for a minute. Lol. What I did change though was that I stopped writing in ‘journal books’ and just make notes on my calendar and I also keep a small notepad next to my bed (I tend to be in bed a lot with the poor Florida heat effects on my body) and write down how I feel each day and what meds I took, and if any extra meds were needed etc.
And I save my notes year after year.
It 100% helps me follow my pain and fibromyalgia ‘pattern’ re: effects from activity, weather,times of stress etc etc.
Then, when I go into really bad exacerbations I can look back and see if I felt the same in the past with the weather or added activity.
I don’t have much else to do anyway! Haha
@Danny you are soooo blessed to have a good pain doc. I’m jealous.
I did also before I moved to Fla. from CT. 2 yrs ago.
Like yours… he listened well, appreciated any info I brought to him, had compassion, spent time discussing things, and managed my pain fluctuations very very well. I should’ve never left there.
I’m on my 5th pain doc in Fla now! Only one was I able to have that all with but she left that practice after just 6 mths! She couldn’t deal with their lack of proper pain mamgement.
There is never any discussion about my pain, I was never examined, and none of those other docs ever even asked me why I was in pain!
I do get my scripts (for now!) and for that I am blessed but sometimes I’d like to ask questions or adjust my meds, try something else etc but…that’s a major no no here! It would being suspicion on you as being an addict.
So ridiculous and mismanagement to the max. It’s surely not practicing medicine!

I know…you thought it was going to be some really cool program to use; there are programs out there. I just use a calendar and/or a black and white journal that is used in schools with lined paper inside that doesn’t pull out by design. Date/time and the pain level. You work a system that works for you. For your appointments. You can very quickly go over a 2 week or one month period by making notes on a small calendar or phone app calendar while making more detailed notes in the journal. A page or more per day depending on YOU.
Pain journals are unique to the individual.

I have spoken with many Neuro surgeons They refuse surgery
How many surgeons do you know that actually had it done? Very very few. It was a money maker that caused one of the number one disabilities I know I worked in a disability office Fusion after fusion
Then they say, “you won’t be eligible for any experimental surgeries” because I am so messed up! Surgeon put in nickel wire I’m
Allergic to NI! Big foundation
He refused to tell me. I pretended to order the gauge of the wire from
Stryker! This was big money, folks.
Didn’t come in Titanium
Why? Why do we have no recourse? Oh, now it is micro surgery! We are guinea pigs. Do not look at the FDA website. It’s practicing medicine folks! It’s a continuous process I was told last week that my surgery dome in 2000 would not be done today! Boy, that sure helps me! I lost faith in doctors.
They won’t have the surgery!!!!

Why were all these surgeries allowed to happen when Germany had stopped doing them
For money? We had no rights and not enough education on the spine not being rigid. There should be compensation for this We lost our lives Years of lives!!!

Excellent post, Sandy! I’m so sorry for the difficulties you’ve been dealing, but your advice for pain sufferers to keep a detailed journal is great, as is researching your own condition. I have a good relationship with my doctor of 15+ years and he not only accepts research that I’m able to find, he often is grateful that I’m able to help him learn any new information about my condition.

Taking an active role in researching new developments and potential treatments for our conditions should be welcomed by our doctors. If yours doesn’t, you may want to consider searching for one who does. Chronic, high-level pain requires the best treatment available. And we deserve it, too. Good luck, Sandy!

Robert wrote: “. Having noticed Dr Hanscom’s writings and specific recommendation to his readers, that they keep a logbook and note down what’s happening in relation with their pain, I started tracking my pain and my panic attacks and discovered an odd thing: The back pain was a pro-drome that began several hours before the onset of a panic attack.”

Logging and/or journal-ling one’s pain is an important tool for both you and the doctor. For example, I’ve been experiencing severe bone pain in my hip. Along with a host of other issues for too long after an accident. I absolutely have PTSD several times over; non-combat but traumatic enough to cause me to physically shake. Too often just limping into my doctors office can cause me to start to shake and when I do; my blood pressure skyrockets when it normally sits at a healthy 110/80 [give or take] Panic attacks spike it to 157/130!! Heart-attack range.
PTSD isn’t fun. I see a psychiatrist for my anxiety meds. When my anxiety is managed it is *easier* to manage my pain.

My pain doctor sent me to the psychiatrist, my pain doctor is also my primary, qualified enough to manage it himself. He wanted that burden shifted; now he doesn’t like not having control over my anxiety medication. I’ve done sleep tests; I don’t have low blood oxygen and get about 6hrs of good sleep. My anxiety peaks from noon-4pm; unless there is other stressers. That’s just a normal day. Gabapentin + half dose of anxiety med gets me to sleep long after my last 12hr tablet or any other pain med. Those work better for me earlier in my day and not so well at night due to minor agitation they can cause. I’ve been tracking my pain for years and years.

I take the log books in. Sometimes I take research in too. Logging pain is an awesome tool to help patients. Truly.

My last appointment saw me receive a dose decrease; no justification for it except FEAR of GUIDELINES! Even though he thinks I am terminal cancer now [think myeloma]. Doctor of 7yrs asks about the severe bone pain that hasn’t improved with anything – nerve cauterization, bursitis sac injections to reduce swelling [helps, some but bone pain still there] He asked me on my last appointment “this is NEW pain isn’t it?”
Me: “If 2 years is new? Then you can call it new pain….go back to when you started the first bursitis sac injection, the paralysis of left leg/foot, re-read the MRIs and nerve conduction testing if needed but it’s all here and in your records too…”

He then started to complain about the amount of weight I had loss. Again, this is logged, because the hip pain started in 2015, the paralysis hit in 2015 and right after that…? 50lbs lost in under 6 weeks. Logged, journal-ed to the month – date – day. I can say pull up records from this month and this year; you will see I have been mentioning the sudden drop in weight when I started to lose again but he only took notice of it once I hit 102lbs!! Since, I’m neither large boned or tall; the loss of weight, the hip bone pain all of this for 2 years and he finally suggests cancer? And because I’ve lost all this weight – he says he *must* reduce my pain meds by 20mg a day and that I wouldnt’ notice.

Again, my journal has been saying “my pain hasn’t been well covered since 2012…” [because after 2012 he forced me onto Opana; a rubbish drug for a 12hr medication as it has a very low bioavailability – it is hard to absorb orally.] My journal proves him wrong often. As does my research. It’s sad because I think he can be a very good doctor if he stopped letting BAD POLICY dictate his treatment for me.

BTW, Opana was taken off the market because it was dangerous; low bioavailability likely caused some to over-take them looking for relief [whereas I suffered in silence with my journal in tears over being stuck at home because my pain isnt’ covered] and now cancer isn’t enough? Now 2 years of warnings and proven warnings and all my family behind me? Not enough to stand up to the guidelines and say “there’s no justification to reduce medication – pain increased – cancer concerns over persistent bone pain in hip” What about notarized, certified letters from my family to him?
They’re almost as devastated as me about the drop in pain meds because being off of Opana for 12mos had helped me be more active at least despite more pain. They’ve watched me finally go out again. They know my pain almost as well as I do and they know my bad days are more than good ones. They also know – I never run out of my meds, never take extra just because the pain is bad.

MMJ can and does help – Florida still can’t get it legislated right. Journal’ed it. How much, when, concentrate, topical [make my own topical pain cream with MMJ-coconut oil and cloves! ] vaporized. As it is now – too expensive for me to go onto completely and sadly wouldn’t cover all my pain either – nor does it work well for my anxiety. Though some strains work better. Journal which is which.

Kratom – bali or thai [not Maeng da] has helped with the dosage change. It helps clear the head of fog in the morning. 2 x 32g capsules. 65 capsules cost me 20$. I’m sure people abuse this substance. Not sure to what end, I feel no buzz. Maeng Da is their preferred and I didn’t like it’s speed like effect. Kratom is similar to Kava Kava. [and you got it…. JOURNAL’ED]

Because the day I have to find another doctor – if my records do not match my journal my doctor will learn another word; REDACTED. /pissy rant off

Oh, how I wish I could go back in time now. I had an anterior fusion in 1998 and have been in chronic pain ever since. It turns out I was the FIRST surgery of this kind by this surgeon. After I went back to him and told him the pain was worse than ever, he just said “My job is done. You will just have to live with the pain”. I was dumbfounded. I have been on opioids ever since (the ONLY thing that helps) and I never abuse my medications, because I am terrified of an accidental overdose, etc. Now, I admit, I am completely dependent on Oxycontin to function. That n itself is worrisome since now there seems to be a war on opiates. I hope this article reaches millions of back pain patients so they don’t have to undergo what I did and live in a pain filled existence forever more! Thank you. I understand everything now. If only, I could reverse time….I would never have allowed the surgery!

@M I truly believe that you are one of the lucky ones to have good results.
I’ve met very few folks with spinal surgery post op success.
I wish it were my case, having had 4 failed spine surgeries and still lying on ice several times/day….I cannot lie on my back without it because of the constant lumbar burning when I lie down.
Freezing the pain away helps me be capable of getting in bed to rest.
We all have our stories and I do know now that I most likely did not need the initial fusion surgery had I been told to try other modalities first….long sorry.
I’ve been on a very long journey with this broken painful body of mine and have learned a ton!! My future is very bleak, strictly due to my surgeries.
I was much better and functional before them…
Thank you Dr. Hanscom for bringing forth some truth, as a surgeon. I needed to read your words.

I can’t help but snicker at the timing of this excellent article. I am a participant in the chronic, intractable pain “community” due to traumatic brain injury caused by electrocution. However, I have past experience with back surgery and, just last night, I may very well have ruptured another disc!

In 1982, at the age of 21 (!), I injured my back while playing college basketball. I did everything recommended by Dr. Hanscom in this article before resorting to surgery. I finally had a L-5 discectomy in 1987. It was very successful, in terms of eliminating the chronic pain, but I was always susceptible to spasms, because of awkward lifting or twisting movements, but also because of the occasional stressful life situation. I struggled to understand the cause and effect of stress and back spasms, but many years of experience taught me that it truly existed. (I am not saying that stress, by itself, causes back problems. My experience is that there must be a preexisting injury/disorder in the back that exists and can react to stressful situations with spasms and/or pain.)

Fast forward to 1991, when my electrical accident occurred. The chronic, intractable head pain that has been a permanent result of the electrocution instantly stopped my participation in athletics. I went from a collegiate athlete to spending 70-80% of my life in bed, surrounded by blackout curtains and semi-soundproofed walls and doors. Obviously, my physical conditioning began to deteriorate immediately, which also lead to weight gain. (I’m 6’2″, 215 lbs – doesn’t seem overly heavy, but I’ve always been very thin.) In 2011, I ruptured the L-4 disc by making a small, twisting movement while lifting a relatively lightweight object. Having the back pain combined with the head pain was devastating. I knew, in my heart, that another surgical procedure was necessary, but I tried everything I could to avoid it. Within 3 weeks, the sciatic pain was unbearable and I developed a “dead foot”. Again, I had a successful discectomy procedure. But, because of the head pain, I am unable to do the physical conditioning required to strengthen my core muscles to reduce the pressure on my spine.

Last night, I was slightly bent over while petting our cat and… BAM! I don’t know for sure what my condition is, but it was definitely a familiar feeling. It felt like the L-3 disc may have ruptured. I have been dealing with a particularly severe cycle of head pain for about 6 months and now this?! Then I open my email from National Pain Report and read this article – sometimes, you just have to laugh. It’s better than the alternative.

I had the opposite. After lying on ice for 12 years I had a 3 level fusion/laminectomy from front and back.

Upon awakening, I knew I had surgical pain but the nagging ever present horrors of the past 12 years were gone.

Unfortunately I had let it go too long and eventually ended up with my whole c-spine fused/lam but have great luck there.

The lower l5-6 has post laminectomy pain.

I couldn’t carry on until my surgeon intervened.

We all have different outcomes. I am sorry yours didn’t work. The spine throws pain in different places than you would think. I get that. But not all spine surgery comes out bad. Please don’t scare patients who truly need it.

Dr. Hanscom has the proper philosophy, without $$$ being the motivation, to perform surgery on the complaint of back pain. As a two time spine surgery patient, looking back, I believe that proper judgement by the physician was used in my case.

After experiencing leg and back pain daily to the point that sleep had become nearly impossible, I sought medical care. First with my “General” MD of 35 years. Refereed by him to a surgeon, the surgeon who I knew personally, advised me to “carry on” the best I could. He did in fact offer non opiate medication which did help. Of course before any advice the protocol of proper imaging was done.

After about a year, and being “upped” to opiate medication, a very small dosage, the pain was still prevalent in life, consistent, and seemingly getting worse. The surgeon knew the outcome of surgery, could make the pain…..worse. Surgery was decided i by the surgeon to keep me “from” having t use medication……for the rest of my life.

The first surgery “went” well but, not only did I still have back pain, it now involved a different area of my back after enough surgery heal time had passed. Still on opiate medication, still a low dose and not a “strong” medication, the pain wold not yield enough to do what I do. Make a living for my children and spouse, so that we, that we, my spouse and I could pay for our two childrens’ college education as well as meeting our recurring debt.

Investigation, again about one year after the first surgery, proper imaging was again done. This time, a worsened condition was exposed. The surgeon advised that I needed a “fusion” of vertebra in the attempt to stop or slow the pain. He advised that the “statistics were that about 75% of the pain could be arrested with fusion surgery. I don’t believe that this is an accurate number but, it sounded like hope.

The fusion surgery was the most painful incident in my life and, as a home builder, I knew minor aches and pains. Nothing like the surgery pain and, and with a “believed” 75% reduction of pain advised, I could endure to see the heal process of surgery so that a better life, a pain “less” life could continue.

Twenty years later, the continuous back pain has never stopped. It IS worse than when I first was besieged with pain. All the “normal” pain relieving procedures, physical therapy, steroid injections, spinal infusions, chiropractic ( which should maybe have been done before any surgery), back braces, mobile and home use type, even a psychologist was advised to help me “manage” still continuous pain.Already in excess of 90 mme some 15 years ago, I was still employed.

Dr. Hanscom, is exactly right with his narrative and I am very happy for him to relate his observations as a surgeon for those that do have back pain. DOT/GOV in the mis-guided attempt to “help” opiate abuse problems, is in fact creating worsening pain management, nearly impossible pain management assistance for those of us that are “experienced” pain patients. I believe that so many physicians believe and wish to help the patient but, it often turns into a nightmare, for the patient. Now with 90 mme daily, it is useless if the pain is so severe that “rescue” at the emergency room or an “urgent” care facility will simply turn the patient away. Citing, you are a pain patient, see your provider., which s now also……useless.

The CDC “mis-guide-line” has offered a solution to ALL people in pain, with the “absolute” solution.. Even those that choose to misuse or abuse illicit and prescribed medication with “one stroke of the pen”. Deny adequate medication to everyone through intimidation to the providers. 90 mme daily is ONLY a reference to providers. Yeah, right. It is an asinine policy. A “policy” adopted unilaterally by all the states in the union. All the states “medical health authorities”.

It seems that any insight into a decaying health condition, physiologically and psychologically, was not very important. A set dosage of opiate medication for all pain patients was enough. No regard to beneficial longevity of use. No matter if the medication benefited the patient to remain self reliant, self sufficient, in any capacity. The possibility of a decaying lifestyle seems to have been disregarded.

Mounting “problems” already known by the patient, was inevitable. The “guideline” seems to have not considered the hardship, the pain and suffering to worsen with 90 milligrams of morphine equivalent. A “set” amount of dosage would be “ample” for all pain patients.

Ample to reduce the number of prescriptions written. Savings for our insurance companies for prescriptions filled. Is the mis-guided-line really curbing “overdose” from opiates as is, the stated intent? I don’t believe the truth will ever be published by DOT/GOV. REAL hardship in almost every patient that has used their personal medication in a responsible manner, now that 90 mme is “law”, will not be reported by any “main stream” media source. The real hardship will only be known through advocacy networks, social media networks, and the insufficient dosage that is now being prescribed, by our providers, is affecting lives to the point of self destruction, destruction monetarily, the inability to be self reliant, and calling upon the generosity and humanity of family and friends to be “pushed” to the point of extinction.

EVERY pain patient is an individual, with different physiological attention required, , and deserve to be treated as an……individual. Our doctors discretion, even a practicing physician with decades of successful prescribing, documented patient results, patients with a close”eye” kept on them, have been threatened with their license loss or revocation to exceed 90 mme daily without “accurate justification as stated to me by my state medical board representatives. Attorneys for the medical board!

I am YET to attain exactly “what” accurate justification means. I can be assured that the justification is NOT an easy process for our providers. One might say, impossible. The notion that a set maximum dosage for every pain patient, regardless of all the factors that are considered when a doctor prescribes opiate medication is just beyond average intelligent comprehension. Our policy makers should realize that with ANY radical policy change, especially with “taboo” opiate medication, an alternative for a real health condition that IS being caused to worsen, must be considered before said policy change. To disregard a medical condition worsened through “policy”, by an admitted millions of patients, ANY direction, advice, or assistance for those patients that have benefited with opiate medication in excess of 90 mme, is non existent. Non existent from our providers, specialists, and governing “local” or state medical bodies. Direction for a mounting problem for the pain patient to even consider other than illicit use of drugs, “sucking up” the eternal pain, or attempting to correct the total disregard of “personal”, individual, medical treatment.

Wish I had read more of these types of articles in the 90’s. Seemed as if surgeons were just bent on cervical fusions. I had 2 that failed and the 3rd has me still in constant pain.
I think surgeons were a bit over zealous. Plus, one doesn’t realize the sound is meant to be FLEXIBLE,
First surgeon definitely did not point this simple fact. I wish I had surmised this myself.
Don’t rigidly stabilize part of the spine. The rest will over compensate and deteriorate.
Germany had stopped long before the U.S. I’m afraid money was a prime motive here.

Thank you for mentioning that there are other aspects of pain that need to be dealt with for a better outcome.
I really admire and respect your telling of what experience has shown you.
All doctors should read your book ✨

Having a lifelong experience with spinal socliosis (55/45) and recurrent panic attacks, I emerged from a recent car crash with painful spasms in my lower back, that worsened after the death of my father. Having noticed Dr Hanscom’s writings and specific recommendation to his readers, that they keep a logbook and note down what’s happening in relation with their pain, I started tracking my pain and my panic attacks and discovered an odd thing: The back pain was a pro-drome that began several hours before the onset of a panic attack.

I told my doctor about my discovery and we adjusted my anxiolytic medication last month.

Now I’m starting to get more exercise.

Knowing that the back spasm is a form of panic…and that I can relieve it with a Xanax tablet and some bed rest, is absolutely liberating.

I still have significant spine issues. The curvature places one of my ribs in the plane of my clavicle and occasionally the two bones bump one another. So I have to walk weird and look funny…and at some point I may need some sort of brace for it.

But unless someone invents a way to straighten each spinal disc out for me, surgery seems a poor option at this time.

That’s exactly why it’s dangerous, to construct a sort of religion around science and science-derived medical practice. The mere fact that the physician wears a scientist’s lab coat, does not make every word the physician utters, into a scientific fact. The scientific method is one of repeatability and experimental proof, rooted in Causality. If effects have causes, and we repeatedly get the effect by applying the cause, we’ve proven a cause-and-effect relationship, hence, scientific proof. It’s that scientific proof, that makes theory into fact.

Merely believing that an operation is better than some other treatment modality, does not cause the belief to become true.

And the faith we put in any idea, depends on the reliability with which the idea proves itself reliable. Forcing oneself to continue believing an idea, that is failing to prove itself true, leads to a crisis of faith, and resolving that crisis requires sorting out the proven from the disproven.

The late Dr Nathaniel Branden, who invented the term “self-esteem”, was fond of pointing out that we humans are our own harshest critics and for good reason. Any skill we don’t know ourselves to possess, is a skill we won’t trust ourselves to have, should we actually need to use it. Authentically knowing my limitations, empowers me to do lots of things, staying within those limitations.

Do not try to tell me I will transform into Superman, if I go under the knife to have L3 fused to L4…because I won’t believe it. Tell me instead that there’s a pinched nerve in there, and when it’s relieved of pressure, I’ll go back to being about as limited as I was, before whatever mishap caused me to have a nerve pinch between L3 and L4.

Giving people false hope and a letdown, is unhelpful to their self-esteem and erodes their trust in the medical profession. We gain accurate self-esteem by discovering our abilities and finding uses to which to put those abilities.

What do you say to one such as myself who’s had C4-C6 ACDF (2006), C3-C4 ACDF (2012) failed due to same surgeon not removing hardware C4-6 and doing C6-7 that was compressing my nerve? I had Bilateral TOS surgery 2001 and still have TOS for which I must wear a brace HS. I’ve done numerous P/T before and after surgeries, was in traction, O/T, acupuncture, massage, chiropractic, tens unit, and have done all modalities required. I had countless ESI’s, Facet Blocks, before and after surgeries, you name it I’ve done it. My previous neurosurgeon didn’t like being called out on his mistakes and I had to find a new one. He now wants to do posterior C3-T1 and L3-S1 after 1 year recovery time for each, but can’t fix what was done anteriorly. Due to the two cervical surgeries I’ve arthritis, osteophytes, kyphosis, scoliosis, and my hardware is pushing out. When he did C3-4 he didn’t do as planned, remove titanium from C4-6, clean up all issues and left me with 3 screws C3-4 that’s not sitting correctly causing more issues. A new MRI (2012) prior to C3-4 showed C6-7 issues that should’ve been fixed, but were ignored.
I now have AA due to all the ESI’s that my new neurosurgeon DX’d 2/2017 as others are afraid of being sued. I’ve 8 bulging and/or herniated disc impeding my thecal sac, spinal cord and causing severe spinal stenosis. 2 in my cervical, 3 in thoracic, 3 in Lumbar down to S1. I’ve MS, OA, OP, peripheral neuropathy, migraines,intractable chronic pain, IC, Fibromyalgia and sure I’m missing some.
I don’t wish to be a ginny pig (no punt intended) when there’s never any guarantee surgery will work, I’ve always followed all asked of me and wouldn’t do it any other way.
I’ve been on meloxicam 7.5 mg’s BID for 6 years and before that ibuprofen 800 mg’s all RX’d. It makes me use Prilosec 40 mg’s BID, a baby aspirin to which I’d rather not take. MI’s with CABG run in my family, I had cardiac caths, personal HX of GI bleeds, ulcers and severe abdominal adhesions due to surguries. A femoral hernia repair (2012) my surgeon couldn’t visualize any internal organs.
Why is it physicians are pushing patient’s to surgeons when they’re not surgical candidates due to the new CDC guidelines?

This is the 1st time that I have read about a spinal surgeon who admitted that surgery is not the resolution, especially when the spine is damaged to the point that there is very little left to work with.

I have had an absolutely wonderful surgeon for several surgeries that were all necessary. But he works with a phenomenal Anesthesia Pain Specialist who works with me and a top notch physical therapist. They make a great team.

When I am in severe pain, relaxing is part of what helps with the pain. Without that my back spasms terribly, bending me over. I do have post laminectomy syndrome at L5-6. Although C2-T-3 is heavy, I have rare problems except the tiredness.

You are so right that a good outcome depends on many things- not just surgical perfection.

Reminder, He is peddling a book. It sounds like he believes people consider Surgery on a whim. His book sounds like it just repeats the popular narrative, as if people need to consider these other factors. Unfortunately they can claim whatever they want, because there was not much real research. . Very few Spine Surgeons are even aware of the outcomes of their surgeries. In my experience they do everything they can to avoid a follow up. If they never see it, they have been told by Industry Lobbyists, they can avoid perceived “Liability.”
They avoided Science because it was inconvenient. They never isolated the factors involved in successful versus a “Failed Surgery” this conveniently allowed the to attribute the negative outcomes to the patient. It was not about postponing these interventions, until paralysis and atrophy set in, and telling the patient they had a the wrong attitude. It is the patients fault, they had the wrong mindset, a nebulous explanation, a chicken or egg argument twisted to allow pseudo science to take the place of facts.It is always the patients fault, not the failure to collect the most rudimentary data about these surgeries.
Of course they attribute all of this to the patient, it is easier. It is most telling that they never did any research on the number of people who see a Spine Surgeon for no reason, Perhaps they are having a bad day, or unhappy with their lives, or they are bored and want attention. They never did any research on the incidence of people who are either faking it, or Stressed, or whatever other “Mind Body” condition that would get a desperate person to consider Back Surgery. Depending on the Patients Income level, Gender,and type of work, there is plenty of scrutiny on their reasons to consider an Intrusive and life changing Surgery.
The Negative Outcomes have been censored from Popular Media, which only advertises for the Medical Industry. Fact Based Medical “News” which is mostly Advertising only mentions the positives. With even Surgeons and Physicians peddling pseudo science, we are now virtually Fact Free.It is positively Orwellian, they even have people with severe pain who seek a Surgical Consult believing they are somehow flawed. They are to stupid to understand their own Physical Discomfort and pain. The added Stress of not being believed, or begin denied a referral and having an answer postponed was never quantified. The Industry found that facts were inconvenient. They do Study after Study on “Catastrophising” and Mind Body nonsense where Biased Psychologist and Psychiatrists, get the answers they want, by projecting motives on to patients.
In general a lot of people are stressed, yet hey all don;t seek back surgery, go figure. The “Ulterior Motives” can make the difference in a Workers Comp Case, so the Industry decided to follow that line of reasoning. It was just more Profitable to attribute Psychological Motives, Stress, and “lifestyle’ to a concrete Physical Problem. In Post Fact America it ais about what people believe. Even people in severe pain want to believe there is a magic “Cure.” In their desperation,they will tolerate seeing a Psychologist, after all a Doctor claimed it would “Help.” Then as the Pain becomes more entrenched the Shrink will accuse the of having a motive for the Back Pain, it was nto the initial Injury or the dying nerve, it was not enough love in the patients childhood, or when the pain makes them irritable, they just don’t see the world the right way. They deadpan and force the patient to reiterate the pain, knowingly causing emotional distress. This is a for or Torture” but it is more important to protect the Industries, than to acknowledge that a person is experiencing Physical Pain due to a Physical Problem. Psychologists “Believe”: there is an underlying motive, that the person is defective. They “Believe” the ridiculous unscientific “Studies”, their living depends on it. Big Pharma Marketing helped to promote this too. After al if a person is experiencing Intractable Pain, that can be rather distressing, they can peddle Anti Depressants, Sleep and other Drugs, as they worsen. Once they consider seeing a Psychologist or Psychiatrist, their credibility is gone. By accepting this “Treatment” with no other Choice, thinking it can’t hurt, or that the Physician might be more likely to get tot he root of what is causing the pain, they are already labeled. According to this Surgeon, the Psychological motives are more important than fixing the problem.
Postponing the diagnosis, only increase the stress, giving the the patient plenty of time to lose their Jobs, Education, and even their support System. Family and Friends tend to disappear, after this kind of issue is ignored after multiple Doctor Visits. It gets to tedious explaining, or not participating in activities, It becomes self fulfilling Prophecy, after all of this, a Surgeon is looking for ulterior motives, and their “Therapist” believes people who experience pain have Psychological issues. it would never occur to the to ask, how distressing all of that is. The Industry decided it is the patients fault, and it is more profitable to believe that. Popular media repeats this over and over, and people believe it. They also believe that Acupuncture Cures or whatever they are peddling this week in the New Age Community. There are plenty of false beliefs, people who believe people who experience pain or other health issues deserve it. They believe in Prayer, so as long as it does not happen to them, it is easy to attribute a religious explanation. This is Post Fact America, don’t expect Science to kick in anytime soon! This was a long term Marketing Campaign, about what people believe rather than Facts.

I just bought this book and in the beginning stages of reading it.
Thankyou Dr Hanscome for your honesty and sincere approach to this debilitating
Issue as I’m in my 5 yr of suffering daily, and 2 back surgeries

What would be your answer to a failed artifical disc surgery and degeneration of the spine? I have had 5 back surgeries and I’m only 46. The artificial disc replacement failed miserably and I have had to have lower spine fusions. I would love to be able to stop being on the table every two years but it doesn’t look like that is in my future. I have changed my lifestyle, been put on antidepressants and try to exercise as much as I can. What else would you suggest for someone like me?

My mother has aggressive osteoarthritis and had a failed lumbar surgery where they tried to correct problems with the curvature of her spine and impingement upon her spinal cord. They inserted rods. The assessment of other doctors seems to be that the surgeon didn’t go far enough to stabilize the area and was overly-conservative. She has broken pedicles and broken screws and will soon have another extensive surgery approaching from both the front and the back of her body. It is hard to undo the harm that was done. I absolutely believe the first surgery was necessary as she was experiencing intermittent loss of bladder control. She long had foot-drop and was wearing a brace.

I have mixed feelings about everything. And I wonder what my own future brings for me. My mother began having arthritis symptoms in her teens. She was disabled in her mid 50’s. Apparently, her arthritis is “aggressive.” I have cervical spondylosis, degenerative disc disease and a torn lumbar disc. I started having arthritis symptoms in my 20’s and now have it in my feet, ankle, knee(s?), hips, SI joints, shoulder(s?), hands and the cervical spondylosis. It all takes so much energy out of me and makes sleeping less restful as well. I have a gym membership and I walk for exercise.

I haven’t had feeling in my pinky finger for a few months on the left side. My arm goes numb at night some times. I’ve started sleeping on my back (poor position for my sleep apnea), but I think it’s when my shoulder falls back a bit that I have hand symptoms. I’m going to ask my doctor if we can get another MRI (last one was in 2009). That same arm used to go “dead” and feel heavy a few years ago. I could still use the arm/my hands, but it felt like it took a lot of extra “effort” to do so. Lately, I’ve been dropping dishes and struggling to style my hair but I do have arthritis in my hands as well.

I worry about my future, seeing where my mother is. She needs two more surgeries, they say. One for her lumbar spine and another for her neck to put “cages” in where she previously had a cervical laminectomy (her initial surgery).

In 1990 I took a really bad fall. Broke my spine at T9, T10, T11 and T12 while this was painful what drove me up the wall was the discs at L4-L5 and S1. I saw almost every neurosurgeon in my city and some as much as 3 hours away. At that time there was very little they could do for me. One of the reason being I was on blood thinners and had been since early 1974. Finally my neurologist met a physician from Amsterdam who was going to be moving to my state later that year. He talked him into making me an appointment after he looked over my records. He was working on doing interbody fusions using cadaver bones. He wanted so bad to help me and I wanted my life back. The first surgery went well and after 14 days flat on my back I finally got to the day I could stand up. Within seconds I was in horrible pain and would have been in the floor if not for the nurses. The fusion broke apart and I was paralyzed. Later that night he attempted to redo the fusion. There were problems from the start – I got a really bad infection in my bones. The fusion wouldnt heal. Months and months in the hospital. I dont know who felt worse my doctor or me. He asked me “would you want me to try again”. Of course. I still wanted my life back.So he tried again. This time while it didnt heal properly with years of physical therapy I was able to stand, then walk with a walker, then a cane. It has been over 20 years and the pain is something I have to battle everyday. I have taken some really bad falls. One ended with me hospitalized for a skull fracture, broken nose, broken arm and a couple of broken ribs. I have been on morphine since 1990. Have learned what not to do and how to do it. How to make myself relax and meditate. Lots of ways to help the pain. I hate taking the pills and have even considered surgery again. But have had a couple of neurosurgeons tell me “NO WAY”. So I have to defer to their expertise and there is still a little part of me that remembers the first surgeries. I still remember Dr. M standing at my bed and telling me that I had three minutes a day to feel sorry for myself. Then to get off my butt and do something that brings me joy.And it is probably less than 3 minutes most days. But so happy to see a doctor tell it like it is. Surgery has risks and sometimes it goes very wrong even with the best of doctors.

I understand your position in this and have gotten a no for thoracic surgery a couple times. I learned my back it wanes and ebbs with pain. It is also the other side with my neck. I will choose surgery if it affects my spinal fluid glow. It includes pain too. How do you feel if it is a 50/50 chance at good or bad. Some of my stress is not from saying no it is the why not. Do you feel you explain it and how can we have spine surgeons understand when you hear no how can you help us get why? Pain or not there are several different reasons to say yes or no and I would like more honesty and not just I can’t from the docs. Pain needs to be addressed and when we can’t get surgery we get put on the back burner for pain as well. The guidelines should have been fought harder to be more patient oriented. We get screwed when we are told no too. How can we fix the broken med system? How can we all of us get to a point the truth is pain meds or pt or any other modality works together not separated by a media born epidemic.